We report the first case of Superior Mesenteric Artery thrombosis in a patient with COVID-19 pneumonia in Asia. After favourable evolution of disease with anticoagulant therapy, there was mesenteric ischemia manifested by acute abdominal pain. Though surgical exploration and resection of gangrenous bowel was successful, patient succumbed to vasoplegic shock and multiorgan dysfunction syndrome.
In the course of COVID-19 disease, hypoxia, inflammatory mediators, thrombocythemia, immobilization, sepsis, liver injury secondary to ACE2 receptor expression may predispose to arterial and venous thrombosis [2,3]. In our case, there was serial increase in platelet levels with sustained elevated CRP levels (table1) suggesting reciprocity of thrombotic and inflammatory state.
Till now, only five cases of SMA thrombosis in COVID-19 positive patients are reported in the world till now (3,2,1 patient in Strasbourg, Paris and Italy, respectively) [4-6]. Of these, one patient with multiple comorbidities was managed conservatively but did not survive. In the 4 operated patients, only two(28 years female, 52 years male) survived while one (56 years male) was still on ventilatory support. Surgical procedures performed were: Jejunal resection with laparostomy followed by double jejunostomy and abdominal wall closure 2days later(28 year female), bowel resection and side to side stapled anastomosis (52 years old male). Microthrombi and inflammatory mediators were postulated to cause mesenteric ischemia. Though anticoagulation did improve disease evolution, sudden abdominal pain was noted in both cases, in spite of continuation of anticoagulation in first and after cessation of heparin post discharge in second case. CT Scan was diagnostic in both cases.
In Mesenteric ischemia, the time lag between onset of symptom to treatment is crucial for good outcome. The optimal time for intervention is initial 12 hours from symptom onset, when it is possible to perform vascular surgery effectively without requiring intestinal resection . However, patients with COVID-19 often present late or treatment of respiratory symptoms is given precedence over abdominal symptoms . Mucosal ischemia may further induce massive spread of virus from bowel epithelium leading to vasoplegic shock after surgery, as was noted in our case .
In management of any patient with COVID 19 disease, a holistic approach should be adopted with evaluation of digestive symptoms along with respiratory. SMA thrombosis should be suspected if patient has abdominal distension or pain with existing thrombocythemia with increased inflammatory markers. For diagnosis, Contrast enhanced CT Scan should be done and it may need to be repeated to see the progression of disease. Emergency laparotomy may have a favourable outcome if done immediately after onset of abdominal pain and before onset of any new organ failure.